Reimbursement

I. scope of use of personal account

The personal account of the insured in the first file of the basic medical insurance is used to pay the basic medical expenses of the outpatient service of the insured, the local supplementary medical expenses, and the expenses of purchasing the drugs within the scope of the medical insurance catalogue in the designated retail drugstore with the prescription issued by the doctors of the designated medical institutions in the city. The insufficient part of individual account shall be paid by the individual.

If the insured of the first level of basic medical insurance has been insured for one year in a row, and the outpatient basic medical expenses and local supplementary medical expenses paid by the individual in the same medical insurance year exceed 5% of the average wage of the on-the-job employees of the city in the previous year, the excess part shall be paid by the basic medical insurance major illness pooling fund or local supplementary medical insurance fund according to the provisions, and the insured shall be paid for the expenses over 70 years old Pay 80%

II. Other uses of personal account

If the accumulated amount of the individual account of the first class insured of the basic medical insurance exceeds 5% of the average wage of the on-the-job employees of the city in the previous year, the excess part can be used to pay the following expenses

(1) the cost of over-the-counter drugs within the scope of the catalogue of drugs for basic medical insurance and local supplementary medical insurance purchased by the designated retail drugstore;

(2) the basic medical expenses and local supplementary medical expenses paid by myself and his / her spouse and lineal relatives who have participated in the basic medical insurance of this Municipality when they are in a designated medical institution for medical treatment;

(3) expenses for physical examination and vaccination of myself and his / her spouse and lineal relatives who have participated in the basic medical insurance of this Municipality;

(4) other medical expenses prescribed by the state, Guangdong provincial and municipal governments.

III. entrusting others to prescribe medicine

If the insured entrusts others to prescribe the medicine, Party B shall ask the entrusted person to issue the social security card and outpatient medical record of the entrusted person. When charging by computer, the account shall be provided with the password for direct input. If the password is not set, the original ID card of the entrusted person shall be checked. Meanwhile, the original ID card of the entrusted person shall be checked and the ID card number shall be filled in the back of the prescription, signed Leave a contact number.

IV. outpatient treatment of level 2 and level 3 of basic medical insurance

The outpatient medical expenses incurred by the second and third class insured of the basic medical insurance in the selected social health center of this city shall be handled according to the following provisions

(1) for class A and class B drugs in the list of drugs for basic medical insurance, 80% and 60% of the community outpatient co-ordination fund shall be paid respectively;

(2) for single diagnosis and treatment items or medical materials in the basic medical insurance catalogue, 90% shall be paid by the community outpatient overall planning fund, but the maximum payment shall not exceed 120 yuan.

The outpatient medical expenses incurred by the insured due to the condition of the insured and the consent of the settlement hospital for referral to other medical institutions, or the emergency rescue outpatient medical expenses incurred in the non settlement hospital due to work or business trip

90% of the payment standard of the community outpatient co-ordination fund as stipulated in the preceding paragraph shall be reimbursed

In other cases, outpatient medical expenses incurred in non settlement hospitals will not be reimbursed by the community outpatient co-ordination fund

V. starting line for hospitalization

The basic medical expenses and local supplementary medical expenses incurred by the insured in hospital shall be paid by the insured if they do not exceed the starting line; the part exceeding the starting line shall be paid by the basic medical insurance serious illness co-ordination fund and the local supplementary medical insurance fund according to the regulations.

Deductible:

100 yuan for hospitals below the first level in the city;

200 yuan for secondary hospitals in the city;

300 yuan for tertiary hospitals in the city;

For medical institutions outside the city, 400 yuan has been transferred or filed, and 1000 yuan has not been transferred or filed.

VI. proportion of hospitalization payment

The basic medical expenses incurred by the insured in hospital and the part above the starting line of local supplementary medical expenses shall be paid in the following proportion:

(1) if the insured has received the employee's endowment insurance treatment in this city on a monthly basis and paid the basic medical insurance premium at 11.5%, the proportion of payment shall be 95%;

(2) if the insured of the first level of basic medical insurance pays 8% of the basic medical insurance premium and the insured of the second level of basic medical insurance fails to receive the pension insurance benefits of the employees in this city on a monthly basis, the payment proportion shall be 90%;

(3) for the insured with three grades of basic medical insurance who are hospitalized in the first level hospital, the second level hospital, the third level hospital and the hospital outside the city according to the regulations, the payment proportion shall be 85%, 80%, 75% and 70% respectively. The hospitalization medical expenses incurred in the non settlement hospital for emergency rescue due to work and business trip shall be paid 90% of the hospitalization payment standard of the visiting hospital.

VII. Inpatient materials

The special medical materials and disposable medical materials, installation or replacement of artificial organs within the scope of the basic medical insurance diagnosis and treatment project and the unit price of more than 1000 yuan shall be paid by the basic medical insurance serious illness overall planning fund according to the following provisions, but the maximum payment shall not exceed the popularization price published by the municipal social insurance administrative department:

(1) for domestic materials, 90% of the actual price shall be paid;

(2) for imported materials, 60% of the actual price shall be paid.

VIII. Inpatient bed fee

The hospitalization bed fee of the insured shall be paid by the basic medical insurance serious illness pooling fund according to the actual hospitalization bed fee, but shall not exceed the following standards:

(1) for the first and second class insured of basic medical insurance, the maximum amount of payment shall be the first class of the government guided price of a-room double room bed fee for ordinary ward of non-profit medical institution determined by the municipal price authority;

(II) three level insured of basic medical insurance, the maximum payment amount is the first level of the government guided price of the bed fee for three-level Room B in general ward of non-profit medical institution determined by the municipal price authority.

IX. violation by the insured

If the insured has any of the following circumstances in violation of the provisions of medical insurance, the municipal social insurance institution may suspend the bookkeeping function of its social security card for 3 months; if the loss of medical insurance fund is caused, the bookkeeping function shall be suspended for 12 months.

(1) lending social security cards to others for use;

(2) obtaining the basic medical insurance fund by exchanging drugs, bartering drugs or reselling drugs;

(3) the amount of drugs paid by the pooling fund exceeds the normal dose through multiple medical visits.

X. the number of diseases enjoying treatment for serious outpatient diseases increased to 7

1. Outpatient dialysis of chronic renal failure

2. Anti rejection drugs for backdoor diagnosis of organ transplantation

3. Outpatient chemotherapy, interventional therapy, radiotherapy or nuclide therapy for malignant tumors

4. Hemophilia special outpatient treatment

5. Special outpatient treatment for aplastic anemia

6. Outpatient treatment of thalassemia

7. Special outpatient treatment of intracranial benign tumor

8. Other situations approved by the municipal government

The outpatient treatment of the above-mentioned diseases shall be approved by the municipal social insurance institution, and the basic medical expenses and local supplementary medical expenses incurred shall be respectively paid by the basic medical insurance serious illness pooling fund and the local supplementary medical insurance fund in proportion.